NYS HOME HEALTH, LLC
Application for Employment

It is this facility’s policy to provide equal employment opportunities without regard to race, color, religious, sex,

national origin, age, or disability.

Applicant Name: Date of birth:

Present Address: City: State: Zip:

Phone: Social Security Number: Are You at Least 18 Years Old? Yes No

Position Applying For: Full Time Part Time Per Visit Shift: Day Night

Part Time Pool Evening W/E

Salary Requirements: $ Date Available: If you are not a US Citizen, have you the right to remain

permanently in the US? Yes No

Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours? Yes No

Have you been convicted of a crime (excluding misdemeanors and traffic offenses) and/or released from confinement following a conviction for any criminal offense within the past 7 years? Yes No If Yes, please give date, place and nature of each such conviction.

Are you presently charged with any violation of the law other than traffic violation? Yes No If Yes, give date, place and nature of each such conviction.

EDUCATIONAL HISTORY

Type of School / Name & Location of School / Circle Last Year Attended / Graduated / Degree
High School / 9 10 11 12
College / 1 2 3 4
College / 1 2 3 4
Other / From:
To:

List professional licenses you possess.

Type of license: Number: State:

List any memberships in professional organizations, honors or activities which you feel would enhance your application, excluding those that would indicate race, color, religion, sex, national origin or disability.

NAME:

List languages spoken other than English:

List other skills applicable to the position for which you are applying, including computer experience, typing speed, etc:

In case of an emergency notify:

WORK HISTORY

Attach an additional sheet listing other work experience pertinent to the position for which you are applying if the space below is insufficient

Company Name: / Address:
City: State: Zip: / Phone Number: / Supervisor’s Name:
Date Started:
Date Left: / Type of Business: Salary:
Full Time $
Part Time
Per Visit / Reason For Leaving: / OK to Contact Supervisor
Yes No
Describe your job title, responsibilities and accomplishments:
Company Name: / Complete Address:
City: State: Zip: / Phone Number: / Supervisor’s Name:
Date Started:
Date Left: / Type of Business: Salary:
Full Time $
Part Time
Per Visit / Reason For Leaving: / OK to Contact Supervisor
Yes No
Describe your job title, responsibilities and accomplishments:
Company Name: / Complete Address:
City: State: Zip: / Phone Number: / Supervisor’s Name:
Date Started:
Date Left: / Type of Business: Salary:
Full Time $
Part Time
Per Visit / Reason For Leaving: / OK to Contact Supervisor
Yes No
Describe your job title, responsibilities and accomplishments:

NAME:

PERSONAL REFERENCES: Name: Phone: Relationship:

Name: Phone: Relationship:

PROFESSIONAL REFERENCES: Name: Phone: Company:

Name: Phone: Company:

Please review and sign

In making application for employment:

·  I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.

·  I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

·  I understand and agree that if I am offered employment by the facility, my employment will be for no definite term and that either I, or the facility will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice. I also understand that this status can only be altered by a written contract of employment which is specific as to all material terms and is signed by me and the Administrator of the facility.

·  I understand, if I am an unlicensed person who has direct patient contact, that the agency will perform a criminal history check per State Regulations.

Release: I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my license status and my license history.

Applicant:

Date:

Signature: ______

FOR OFFICE
USE ONLY / References Checked / If hired: Position:
Start Date:
Salary: $ FT PT Per Visit